Provider Demographics
NPI:1356682777
Name:BOUDREAU, MATTHEW RYAN (DC)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:RYAN
Last Name:BOUDREAU
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3091 HOLCOMB BRIDGE RD
Mailing Address - Street 2:SUITE D1
Mailing Address - City:NORCROSS
Mailing Address - State:GA
Mailing Address - Zip Code:30071-1335
Mailing Address - Country:US
Mailing Address - Phone:770-447-9090
Mailing Address - Fax:
Practice Address - Street 1:3091 HOLCOMB BRIDGE RD
Practice Address - Street 2:SUITE D1
Practice Address - City:NORCROSS
Practice Address - State:GA
Practice Address - Zip Code:30071-1335
Practice Address - Country:US
Practice Address - Phone:770-447-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008962111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor